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Health, safety and environmental management at the BP Grangemouth Complex

Overview

During the initial investigations into each
of the incidents the Competent Authority decided to carry out a site wide
investigation by members of the HSE’s Human Factors team into overall
health, safety and environmental management at the Grangemouth Complex to
consider whether underlying human and managerial factors provided a
possible explanation for the incidents. The investigation addressed the
safety management system and safety culture and explored wider human
factors issues both as possible explanations for the incidents and to
establish the current situation across the entire Complex.

The occurrence of three separate incidents
on the Complex within a two week period was of concern not only to the
Competent Authority and BP, but to others including the Local Authority,
Trade Union safety representatives, Members of Parliament (MP’s),
Members of the Scottish Parliament (MSP’s) and the local Grangemouth
population. There was, in addition, some public speculation of whether
issues such as alleged lack of investment or de-manning were contributory
factors to the incidents. In the event the Competent Authority did
not find any evidence to support the allegations that either a lack of
investment or de-manning were contributory factors to the incidents.
Further the information considered by the Competent Authority did not
justify the view that there had been a lack of investment at the
Complex. BP provided evidence that the investment level in the
Complex was above relevant industry benchmark levels.

Previous concerns about health, safety and
environmental management on COMAH issues at Grangemouth had been expressed
directly to the management of the Complex by the Competent Authority in
November 1999. These concerns were accepted as valid by the Complex
Director and as a result there were already on-going discussions between
BP and the Competent Authority, prior to the series of incidents, about
how to effect improvements.

It had been recognised by BP prior to
November 1999 that the historical management and business structure at the
Complex required to be changed. As a result a new Complex Director
was appointed in November 1999 with specific responsibility for
integrating and unifying the management structure. The Complex Director
immediately took action to strengthen the senior management team and in
April 2000 established the Grangemouth Leadership Team. A new single
site health and safety management system and standard was also introduced
as an integral part of the new unified management structure.
Implementation of these initiatives had not been fully completed by the
time of the incidents.

The single health and safety management
system introduced at the Complex was directly linked to BP’s health,
safety and environmental management system framework "Getting
HSE Right (GHSER)". This overriding commitment to
excellence in health, safety and environmental matters can be summed up in
three simple goals:

No accidents;

No harm to
people;

No damage to
the environment.

The incident specific investigations and
key findings have been discussed in the previous sections and each
identified a number of technical issues for the incidents. Each separate
incident investigation also highlighted some weaknesses in the management
systems and procedures which contributed to the series of events leading
up to each incident. Similar findings were also found by the BP Task Force
audit team.

The investigation by the HSE’s Human
Factors team found that, due to the history of decentralised management,
strong differences in systems, style and culture persisted across the
Complex. This history had also inhibited development of a strong,
consistent overall strategy for major accident prevention, and had been a
barrier to cross-site communication and sharing of lessons. The key
findings of the Human Factors team explained why, notwithstanding the high
standards set by BP, those standards were not always implemented and met
consistently over each part of the Complex. The consequences of a
non-unified management structure and differences resulting from the three
historical business streams operating at the Complex, in large part
provided a compelling explanation of the incidents which occurred.

The following schematic sets out the
relationship between the various investigations.

The HSE’s Human Factors team interviewed
a sample of people from all levels across the Complex either individually
or in groups. The questions were aimed at looking for behaviours that were
known from published research to be indicators of safety culture. For
example questions were asked about visible leadership and employee
involvement, as well as on more specific issues raised by employees or HSE
Inspectors, such as management of change, de-manning and commercial
pressures.

Historically there were three business
streams operating at the Complex - Oils, Chemicals and the Forties
Pipeline System ("FPS" - Exploration). Although a unified
management and health and safety management structure had been introduced
there remained significant differences in both culture and management
systems. The investigation concentrated on the former Oils business,
with Chemicals and the FPS mainly functioning as useful comparisons.
The conclusions reached by the investigation refer therefore in the main
to the former Oils business and are not consistent features of the Complex
as a whole.

The Human Factors team found that whilst
shortcomings were present in the Oils business, health, safety and
environmental issues were nevertheless taken very seriously. However the
tendency was to place relatively high emphasis on short-term benefits of
cost and speed and to be readier to make compromises over longer-term
issues like plant reliability. Management was perceived by technicians as
hurried, and managers expressed similar concerns about technicians.
In the Oils business considerable effort and enthusiasm were put into
capital projects and fixing problems, but less focus was given to longer
term programmes of review and continuous improvement of existing plant
than was evident in other parts of the Complex.

The investigation also found that there was
a more optimistic perception of safety performance than might be borne out
by comparison with different performance indicators. This was due to real
and commendable success in managing personal injury rates down to a very
low level, together with a failure to adequately distinguish these
successes from process safety management. This imbalance between the
effort put into personal injury versus major accident prevention was by no
means unique to BP. The Competent Authority and others have found
similar tendencies in other comparable businesses.

While the investigation team found
deficiencies in management style and culture in the former Oils business
these shortcomings were not replicated in other parts of the
Complex. The FPS was, in particular, found to have a more careful
and considered approach to management and general health and safety
issues. The investigation also found that while the Chemicals
business in the Complex did require to improve in some respects there were
many examples of good practice.

BP also employed an independent consultancy
to carry out a detailed analysis of the procedures and systems in place at
the Complex for health and safety management. (See Appendix
3 for further details).